Why Don’t We Starve Them Too?

As my regular readers know, I am opposed to the use of sleep deprivation as an educational tool during residency training. The fact that residents are deprived of sleep as a requirement of their job is undeniable especially given the typical call schedules and the obvious fact that work never stops in the 24-hour-per-day patient processing facilities that most teaching hospitals have become. And yet despite my objections I have never made much of an argument against this practice, at least in terms to which the usual advocates of resident abuse will pay attention, because my distaste is more visceral than intellectual. People do need sleep after all. It’s a biological requirement and I have never felt it necessary to explicitely justify why we need sleep any more than I feel it necessary to explain why we need food and water. We just do.

Imagine if it was a regular practice to deprive residents of food. I have no doubt that there are some with a great deal invested in mistreating residents who would indeed deprive of us food if they could make a case that eating interfered with Patient Care. I also have no doubt that many residents, in full Patty Hearst mode, would come out in favor of the practice. It’s just the nature of the profession, to gain admission to which many would sell their grandmothers to white slavers.
Fortunately, as residents can always cram a microwaved burrito into their mouths and suck down a luke-warm Dr. Pepper, the threat to patient safety is small and it hasn’t come to it yet. But imagine the outcry if it did…or perhaps the lack of outcry as the usual suspects opined that, back in the Good Old Days, they regularly went for weeks without food and the desire of the current generation of residents to eat is a sign of the impending medical apocalypse.

So why not starve residents? We deprive them of sleep every third or fourth day, why not make it a clean sweep and withold food and water as an additional character-building exercise, especially if we’re to operate under the theory that tired residents are as effective as well-rested ones?

Too Much Sun

The principle objection to allowing residents time to sleep is that limiting their hours interferes with continuity of care. It is correctly pointed out that the handoff, or the transfer of care of a patient from one resident to another, is a dangerous time from which all sorts of lethal misadventures can ensue. The new resident, after all, has not been following the patient and may not know the nuances of his condition or his plan. With this in mind, the theory is that by limiting the number of handoffs, the number of potential mistakes can be minimized. Limiting the number of handoffs means keeping the residents at the hospital longer.

Now, I am sure that there is a growing body of competing and contradictory studies comparing the risk to patient safety of the handoff versus sleep deprivation. Both probably result in mistakes but as to which is the worst I can only confess a profound indifference. I don’t care because the premise of the studies, that patients in teaching hospitals are at a significant risk, is so deeply flawed as to make the studies meaningless. This is not to say that there is no risk of mistakes but only that by the very nature of academic hospitals, the risk of mistakes is considerably less than it would be at a hospital without residents. This is obvious to anyone who has ever been in a non-academic hospital but maybe not so obvious to those who, like heat-stunned lizards laying on sunbaked rocks, may have been staring into the dazzling fire of academic medicine for just a little too long.

Consider the typical patient at a hospital which does not have residents. The patient is admitted either through the emergency room or directly from his own physician who most likely will not actually see the patient at the time of admission but only relay a few phone orders to the nurse. (This is especially true of a patient who comes through the Emergency Department.) The patient then languishes until the next morning, at which time his doctor will quickly rounds on his census of admitted patient, writing more orders as needed to solidfy the plan, before heading to an extremely busy day in his clinic. Once he leaves, barring a catastrophe, the patient is on autopilot until his doctor checks on him at the end of the day to write new orders or call for any consults which he has not previously anticipated. Many patients only see their doctor, if at all, for a few minutes during their stay while many others are fobbed off to hospitalists, the hired guns of primary care.
Patients in teaching hospitals, by comparison, are positively coddled. Consider the typical service with its census of fifteen to twenty patients riding herd over which is a senior resident, a couple of junior residents, an intern or two, and often a gaggle of eager medical students. Not to mention an attending physician who, liberated from the exigencies of mundane bureaucratic tasks, is free to concentrate his entire intellect on diagnosis and treatment. Comes the night, the prelude to all manners of medical horrors, and there are several residents from the service actually living at the hospital ready to address any problems, from a request for a sleeping pill to cardiac arrest. Not the full complement of physicians to be sure but as doctors in private practice do not spend the night in the hospital, I fail to see how patients in a teaching hospital are worse off than those poor bastards starving for attention in private hospitals. As to the dangers of handoffs, I’m reasonably sure that I do a better job of signing out my patients to my fellow resident than the private practice physician does to his colleague who will be taking over his call duties, duties that they both can generally perform from home, especially as the standard advice to any patient inquiry, no matter how non-threatening, seems to be, “Go to the emergency room.”

So you see, “Medical Errors,” like “Patient Care,” is nothing more than another blunt weapon with which to bludgeon rebelious residents into submission. It is another despicable appeal to shame and an abuse of the resident’s sense of duty. The fact that most residents buy this argument is because they lack the conceptual tools to refute it. But if you think about it, if handoffs are so dangerous, we may as well never leave the hospital but instead live there, perpetually on tenterhooks, agonizing over every detail and jealously guarding our patients from interlopers like feral dogs over scraps of meat.

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